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PRAKTIKUM URIN Dr. Donny Kostradi, M.Kes. Sp.PK SDU-DK-1107 1.

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Presentasi berjudul: "PRAKTIKUM URIN Dr. Donny Kostradi, M.Kes. Sp.PK SDU-DK-1107 1."— Transcript presentasi:

1 PRAKTIKUM URIN Dr. Donny Kostradi, M.Kes. Sp.PK SDU-DK

2 Pemeriksaan Urin Rutin SDU-DK  1. Jumlah Urin  2. Makroskopis: warna dan jernihnya urin  3. Berat Jenis  4. Protein  5. Glukosa  6. Pemeriksaan Sedimen

3 ………….Pemeriksaan Urin Rutin SDU-DK  Ad.1. Jumlah Urin  menentukan adanya ggn. Faal ginjal,  kel. keseimbangan cairan badan dan  menafsirkan hasil pmx. kuantitatif dan kualitatif urin.  Cara m’ukur juml. Urin: 1. Urin 24 jam → prod. dewasa ml 2. Urin siang 12 jam & urin malam 12 jam→ prod. U. siang 2 sp 4 x lebih banyak dr u. malam 3. Timed specimen pd sesuatu percob. ttu → detil u/ juml. absolut 4. Urin sewaktu → u/ protein dan GDS

4 ………….Pemeriksaan Urin Rutin SDU-DK  Ad.2. Warna Urin  tidak berwarna  kuning muda  kuning  kuning tua  kuning bercampur merah  merah bercampur kuning  merah  coklat kuning bercampur hijau  putih spt susu

5 ………….Pemeriksaan Urin Rutin SDU-DK  Warna urin tergantung besarnya diuresis, mkn bsr diuresis → mkn muda warna urin  Normal: kuning muda sp kuning tua → urochrom & urobilin  Kuning - Normal: Urochrom dan urobilin - Abnormal: bilirubin, obat2an & diagnostika (santonin, PSP, riboflavin (dg resensi hijau)), permen dan kembang gula.

6 SDU-DK  Hijau - Normal: Indikan - Abnormal: obat2 dan diagnostika (methylen blue, Evan’s blue), serta kuman2 (Ps. aeruginosa. B. pyocyaneus)  Merah - Normal: Uroerythrin - Abnormal: hemoglobin, porfirin, porfobilin, obat2 dan diagnostika (Santonin, PSP, Amidopyrin, Congored, BSP) serta kuman2 (B. prodigiosus) ………….Pemeriksaan Urin Rutin

7 SDU-DK  Coklat - Normal: Urobilin - Abnormal: Bilirubin, hematin dan porfobilin  Coklat tua atau hitam - Normal: Indikan - Abnormal: darah tua, alkapton, melamin, dan obat2 (derivat fenol dan argyrol)  Seperti susu - Normal: Fosfat, urat - Abnormal: pus, getah prostat, chylus, zat2 lemak, bakteri2 dan protein yg membeku

8 ………….Pemeriksaan Urin Rutin SDU-DK  Ad.3. Kejernihan 1. Jernih 2. Agak keruh 3. Keruh/sangat keruh - Normal: jika urin dibiarkan/didinginkan, lendir, sel2 epitel dan lekosit yg lambat laun mengendap. Urin keruh dari awal: - Fosfat amorf dan karbonat (>>>): makan >> → kekeruhan hilang setelah diberi as. asetat encer Pengaruh di u. sedimen → kristal fosfat/karbonat >>

9 ………….Pemeriksaan Urin Rutin SDU-DK   Bakteri2 >>: berkembangbiaknya bakteri/ kuman, tp jg o/ bertambah unsur sedimen (sel epitel, lekosit, dsb)   Unsur2 sedimen dlm juml besar: - Urin keruh dan berwarna merah spt air daging eritrosit >> - Urin keruh → lekosit >> → sedimen (+) → tes Donne → sedimen urin + lart. NaOH pekat → massa yg amat kental   Chylus & lemak: urin menyerupai susu encer - adanya butir2 lemak (lipuria) sec. mikroskopis

10 ………….Pemeriksaan Urin Rutin SDU-DK   Benda2 koloid: urin tdk dapat dijernihkan dg filtrasi/ sentrifugasi  Urin keruh setelah dibiarkan: - Nubecula - Urat2 amorf dlm urin asam & dingin → keruh → dipanasi akan hilang - Fosfat amorf & karbonat → m’endap pd urin lindi/basa - Bakteri2 dari luar tubuh → unsur2 sedimen tdk berubah/ bertambah

11 ………….Pemeriksaan Urin Rutin SDU-DK  Ad.4. Berat Jenis (BJ) - Cara pmx BJ: 1. tuangkan urin secukupnya ke dlm tab. Urino- meter 2. masukkan urinometer ke tab. dan putar dg ibu jari & telunjuk lalu baca pd tangkai urinometer setinggi meniskus bawah - Normal:  1,016 – 1,022 (lazim: ) pd urin 24 jam  1003 – 1030 pd urin sewaktu

12 ………….Pemeriksaan Urin Rutin SDU-DK Abnormal: * >> 1030, kemungkinan glukosuria, dlm pmx diagnostik rontgen u/ ginjal - Bl juml urin sedikit, tp hrs cek BJ maka harus ditambah aquadestilata dan 2 angka terakhir dr pembacaan harus dikali 2.  Ad.5. Bau Urin Bau urin dari awal: 1. Makanan: petai, jengkol, durian 2. Obat2an: terpentin, menthol

13 ………….Pemeriksaan Urin Rutin SDU-DK Bau amoniak: akibat perombakan bakteriil dr ureum di dlm kantong kencing → pd urin yg dibiarkan tanpa pengawet. 4. Bau keton: mirip bau buah2an/ bunga ½ layu 5. Bau busuk: akibat perombakan zat2 protein, misal pd carcinoma sal. kencing  Bau urin setelah dibiarkan: 1. Bau amoniak: urin yg dibiarkan tanpa pengawet. 2. Bau busuk: akibat pembusukan urin yg mengandung banyak protein diluar tubuh.

14 ………….Pemeriksaan Urin Rutin SDU-DK  Ad.6. Derajat Keasaman (pH) - Normal: 4,5 – 7,5 - pH asam ec: bakteri E. coli - pH basa ec: bakteri Proteus - Cara manual: 1. dg pakai kertas lakmus  kertas lakmus biru menjadi merah: Asam  kertas lakmus merah menjadi biru: Basa/ Lindi 2. dg pakai kertas nitrazin  teteskan urin di kertas nitrazin → tunggu 1’

15 ………….Pemeriksaan Urin Rutin SDU-DK  bandingkan warna kertas itu dg skala warna yg tersedia  warna kuning pH 4,5  warna biru akan berubah dg bertambahnya pH yg lebih tinggi

16 Pemeriksaan Protein Urin SDU-DK Masukkan urin jernih ke dlm tabung reaksi sp 2/3 penuh 2. layangkan tabung yg berisi lap atas urin di atas nyala api sp mendidih slm 30’’ 3. perhatikan kekeruhan yg terjadi dilapisan atas urin, dan bandingkan jernihnya dg bag. bawah yg tdk dipanasi 4. Jika keruh mungkin disebabkan o/ protein, kalsium fosfat/ kalsium karbonat 5. Teteskan 3-5 tetes lart. As. Asetat 6% (boleh 3-6%) ke dlm urin yg masih panas, jika tetap keruh → (+) positif protein. * Kecuali tes ini tidak bisa dilakukan bila BJ rendah atau BJ >> 1003 dan 1006 tambahkan dg lart NaCl jenuh sebanyak 1/5 dr vol. urin

17 Pemeriksaan Protein Urin SDU-DK Interpretasi: - Negatif (-) : tidak ada kekeruhan - Positif + /1 + : ada kekeruhan ringan tanpa butir2, kadar ± 0,01 – 0,05% - Positif ++/2+ : kekeruhan mudah dilihat & tampak butir2 dlm kekeruhan, kadar ± 0,05 – 0,2% - Positif +++/3+ : urin jelas keruh & kekeruhan itu ber- keping-keping, kadar ± 0,2 – 0,5% - Positif ++++/4+: urin sangat keruh dan kekeruhan berkeping - keping

18 Pemeriksaan Sedimen Urin (Urine Sediment Analysis) SDU-DK  Metoda Pemeriksaan: A. Natif B. Cat Sternheimer Malbin  Bahan: - U. pagi dan segar (diperiksa dlm waktu 3-6 jam) - BJ min: Bl as. Urat >>> → encerkan dg aquadest 1:1 dan panaskan 60 ºC agar urat larut - Bl fosfat/karbonat >>> → tambah as. Asetat 10% dg hati2 → spy urin jernih, tp bl terlalu banyak → eritrosit dan torak rusak

19 Pemeriksaan Sedimen Urin SDU-DK  Metoda Natif: - Urin dicampur dg baik - Reagen: - - Cara Kerja: 1. Pusingkan ml urin dg kecepatan 1500 – 2000 ml (5-10 mnt) 2. Buat filtratnya: sisakan 0,5 ml, selanjutnya kocok hati- hati tutup dg kaca penutup, jangan sp ada gelembung udara 3. periksa/ baca dg mikroskop dg pembesaran lemah (LPK):100 x → lihat sedimen sec. keselu- ruhan dan pembesaran kuat (LPB):400 x → identifikasi unsur2 yg ada

20 Pemeriksaan Sediment Urin SDU-DK  Metoda Pengecatan: - Bahan : Urin - Reagen: Cat Sternheimer Malbin yg tda: Lart A : Methyl Rosalina Chlorida (kristal violet) 3 gr Ethanol 20,0 ml Amonium oksalat 0,8 gr Aquadest ad 80,0 ml Lart B : Safranin 0,25 gr Ethanol 10,0 ml Aquadest ad 100,00 ml

21 Pemeriksaan Sediment Urin SDU-DK  Pembuatan cat: - Campur 3 bagian lart A dg 97 bagian lart B - Saring dan simpan  Cara Pengecatan: 1. Teteskan ± 3 tetes cat pd sedimen (0,5 ml) 2. ketuk2 agar cat merata, kemudian diamkan 3 mnt 3. ambil 1 tetes → buat preparat 4. periksa dibawah mikroskop  Kelebihan pengecatan SM: - unsur2 sedimen tampak lebih jelas  Kekurangan pengecatan SM: - taraf permulaan dpt mengacaukan interpretasi, misal silinder hialin yg banyak granula dpt keliru dg silinder granula, krn granula tercat

22 Unsur-unsur sedimen SDU-DK  A. Unsur Organis (Asal jaringan) * Epithel * Eritrosit * Lekosit * Torak (silinder)  B. Unsur Anorganis (macam2 kristal) * Tidak/Kurang punya arti klinis (kristal urat, fosfat, karbonat, as. Hipurat) * Ada arti klinis patologis ( kristal cystine, leucine, kolesterol, dll) → menunjukkan katabolisme tubuh

23 Unsur-unsur Organis SDU-DK  A. Unsur-unsur organis * Epithel: 1. Skuamosa: btk polimorf, sitopl. lebar inti 1 besar asal: kandung kemih, urethra, kontaminasi vagina 2. Poligonal/ bulat: inti besar, sitopl. Sering berisi gra- nula asal: ren/ ginjal 3. Epithel berekor (transisional): inti besar bulat, sito- plasma. Seperti ekor asal: ureter, pelvis renalis dan prostat 4. Kontaminasi epithel dr vagina atau adanya sel2 tumor

24 Unsur-unsur Organis SDU-DK  * Eritrosit: bentuk bulat, bikonkaf, kdg tampak cekung tengahnya, tidak berinti atau bergranula, refraktil thp cahaya - dlm urin hipotonik/encer: eritr. membengkak dan besar - dlm urin alkalis/hipertonik/pekat: eritr. mengkerut, dinding agak rata (Crenasi)  Harga normal: 1-3 sel LPB atau s/d 2500 eritrosit/ ml urin ** U/ hindari kontaminan, pake urin kateter ** Sumber kesalahan: - yeast cell/jamur: ukuran tdk sama - kristal amonium urat - tetesan lemak ( dripped fat ) → larut dg diberi as. Asetat 3% ( lewat tepi kaca penutup)

25 Unsur-unsur Organis SDU-DK  ** Sumber kesalahan: - masif hematuri : karena kesalahan teknik kateterisasi ** Positif Palsu: - erithrosit hemolisis - tertutup unsur-unsur lain yg jumlahnya besar  * Lekosit: - bentuk bulat, lebih besar dr eritrosit, mengandung inti (1 atau lebih, akan tambah jelas dg penambahan as. asetat 3% (urin asam), sitopl. bergranula. → Bila urin tidak segera diperiksa → lekosit rusak bentuk amorf detritus.  Harga normal : - ♀: << 15 sel / LPB - ♂: << 5 sel/LPB atau s/d 3000 lekosit/ ml sedimen urin

26 Jenis Unsur Sedimen Unsur Organik > Epitel > Silinder > Spora > Oval Fat Bodies > Spermatozoa > Pseudohypha > Leukosit > Parasit > Eritrosit > Bakteri Unsur Anorganik > Kristal Normal √ pH Asam: As. Urat, Natrium Urat, Kalsium Sulfat √ pH Asam: As. Urat, Natrium Urat, Kalsium Sulfat √ pH Asam/ Netral: Kalsium oksalat √ pH Asam/ Netral: Kalsium oksalat √ pH Alkali/ Netral: Tripel Fosfat √ pH Alkali/ Netral: Tripel Fosfat √ pH Alkali: Kalsium karbonat √ pH Alkali: Kalsium karbonat Kristal Abnormal > Kristal Abnormal - Sistin: Leusin, Tirosin, Kolesterol, Bilirubin Obat: > Obat: Sulfonamida 26SDU-DK-1107

27 27 Cara Pelaporan Unsur Sedimen Urin menurut JCLLS Sel darah dan epitel dilaporkan: Protozoa dilaporkan 1+ → < 4 sel/LPB Negatif (-) → 0 sel/LPB 2+ → 5-9 sel/LPB Positif satu (+) → 1-4/ LPB 3+ → sel/LPB Positif dua (++) → 5-9/ LPB 4+ → 30-1/2LPB Positif tiga (+++ → >10/LPB Silinder dilaporkan: Negatif (-) → 0 sel/LPK Negatif (-) → 0 sel/LPB Positif satu (+) → 1/100 LPK Positif satu (+) → 1-4/ LPB Positif dua (++) → 1-10/LPK Positif dua (++) → 5-9/ LPB Positif tiga (+++) → /LPK Positif tiga (+++ → >10/LPB Positif empat (++++) → >100/LPK Bakteri dan Jamur dilaporkan: Negatif (-) → 0 sel/LPK Kurang-Lebih (±) → Jarang/ LPK Positif satu (+) → Dijumpai sedikit/LPK Positif dua (++) → Banyak/LPK Positif tiga (+++) → Penuh/ LPK LPB → Perbesaran 10x40 LPK → Perbesaran10x10 Kristal dilaporkan

28 (Urine Sediment Analysis) SDU-DK  Struvite crystals are the most common type in urine from dogs and cats. They are often seen in urine from clinically normal individuals. Though they can be found in urine of any pH, their formation is favored in neutral to alkaline urine. Urinary tract infection with urease-positive bacteria can promote struvite crystalluria (and urolithiasis) by raising urine pH and increasing free ammonia. Pemeriksaan Sediment Urin

29 (Urine Sediment Analysis) SDU-DK  Cylindrical bilirubin crystals have formed in association with droplets of fat, resulting in a "flashlight" appearance. This form is less commonly seen. Bilirubin crystals are seen most commonly in canine urine, especially in highly concentrated specimens. They are less common in urine of other species. In dogs, they often are of no significance (healthy dogs can have low, but detectable, bilirubin levels in urine).

30 Bilirubin crystals SDU-DK  Bilirubin crystals (or positive chemical reaction on the urine dipstick) in feline, equine, or bovine urine should be investigated since an underlying cholestatic process is likely. (Urine Sediment Analysis)

31 SDU-DK Calcium Carbonate Calcium carbonate crystals usually appear as large yellow-brown or colorless spheroids with radial striations. They can also be seen as smaller crystals with round, ovoid, or dumbbell shapes. These crystals are common in the urine of normal horses, rabbits, guinea pigs and goats. They have not been observed in canine or feline urines. (Urine Sediment Analysis)

32 Amorph crystals SDU-DK Calcium oxalate dihydrate crystals sometimes also can present as "amorphous" when the individual crystals are very small. Examination at higher magnification will reveal the typical "envelope" appearance. Xanthine crystals are usually in the form of "amorphous" crystals. These crystals occur in Dalmations on allopurinol therapy for urate urolithiasis. Generally, no specific clinical interpretation can be made based on the finding of amorphous crystals. Small amorphous crystals can be confused with bacterial cocci in some cases, but can be distinguished by Gram- staining. (Urine Sediment Analysis)

33 Calcium oxalate dihydrate crystals SDU-DK  Typically are seen as colorless squares whose corners are connected by intersecting lines (resembling an envelope). They can occur in urine of any pH. The crystals vary in size from quite large to very small. In some cases, large numbers of tiny oxalates may appear as amorphous unless examined at high magnification. These crystals often are seen in normal urine from horses and cattle. They are less common in normal canine and feline urines. Urolithiasis due to calcium oxalate has been reported in both dogs and cats. In some cases, they occur secondary to abnortmal calcium (increased) excretion due to disorders of calcium metabolism (e.g. hyperparathyroidism). Miniature Schnauzers are predisposed to calcium oxalate urolithiasis, despite no abnormalities in urinary calcium excretion. Calcium oxalate dihydrate crystals can also be seen in cases of ethylene glycol intoxication. If seen in large numbers in the urine of a dog or cat with acute renal failure, consideration should be given to this diagnosis. (Urine Sediment Analysis)

34 Infectious Agents in Urine Sediment Infectious agents of various classes can be observed in urine sediments. In most cases, their significance can be properly assessed only in light of the clinical signs, method of collection, post-collection interval, and other findings in the urinalysis. Click on the buttons below for pictures and more discussion of infectious agents found in urine. 34SDU-DK-1107 (Urine Sediment Analysis)

35 Candida albicans SDU-DK Candida Yeasts in unstained urine sediments are round to oval in shape, colorless, and may have obvious budding (upper panel). They often represent contaminants, and are especially suspect if the sample is voided and/or old. In other circumstances, however, their significance should not be discounted. The pictures shown here, for example, are of fresh urine collected by cystocentesis from a dog that had been on long-term antibiotic and immunosuppressive therapy. The lower photo shows pseudohyphae formation by the yeasts, which were identified on culture as Candida albicans. (Urine Sediment Analysis)

36 SDU-DK Bacteria can be identified in unstained urine sediments when present in sufficient numbers. Rod-shaped bacteria and chains of cocci are often readily identifiable. The images at right show E.coli bacilli from a case of cystitis in a dog. However, small amorphous crystals, cellular debris, and small fat droplets can either mask or mimic cocci. If there is any doubt about the presence of bacteria, a Gram-stained smear of urine sediment (middle panel) should be examined.cocci Urine in the bladder of normal animals is sterile. Though bacteria from the distal urethra and/or genital tract may contaminate voided specimens, they are usually too few to see if a good mid-stream collection was obtained.

37 (Urine Sediment Analysis) SDU-DK  Although phagocytized bacteria cannot be seen in unstained wet  mounts of urine sediment, they may found in stained smears of sediment. The lower panel at the right shows a neutrophil containing phagocytized bacteria. Notice that the nucleus in this cell is round; nuclei tend to become round as neutrophils age in urine.  Bacteriuria of clinical significance, e.g., bacterial cystitis, is usually accompanied by increased numbers of white cells (pyuria). The presence of a few bacteria without pyuria is very rarely significant of infection

38 SDU-DK Fungal hyphae in urine sediment preps most commonly represent overgrowth of contaminants in samples where analysis was delayed. If seen in a fresh sample, especially one collected by cystocentesis, fungal infection of the kidneys and/or bladder should be suspected. Aspergillus terreus (shown at right) has been documented to cause systemic infection including colonization of the renal pelvis.Fungal (Urine Sediment Analysis)

39 Microfilaria SDU-DK  Microfilaria  Microfilariae of Dirofilaria immitis may be seen in the urine sediment in cases of hematuria in microfilaremic dogs. The finding is without significance, other than as an indication of heartworm disease. (Urine Sediment Analysis)

40 SDU-DK Urinary Tract Parasites Capillaria plica is a helminth parasite of the canine urinary bladder. C. felis-cati is the feline counterpart. The ova are similar to those of Trichuris spp. in that they are oval in shape and have bipolar plugs (see picture). Since fecal contamination of the urine could result in the presence of whipworm eggs, the two must be differentiated. If the ova were seen in a well- handled urine collected by cystocentesis, fecal contamination could be ruled out. Additionally, the ova of C. plica are colorless and rougher in texture compared to the smooth, yellowish eggs of T. vulpis. Dioctophyma renale, the giant kidney worm, has large, yellow-brown, thick-walled ova with a characteristic wavy surface (not pictured). Eggs may be seen in urine if a gravid female worm is present. Though endemic in areas of Canada, the infection is very rare in the United States. (Urine Sediment Analysis)

41 Less Common Crystals The crystals listed on this page generally are not expected in urine from normal individuals. It is important to recognize these crystal types, since some fairly specific interpretations can be made based on their presence. Click the buttons below for pictures and discussion of these crystal types. 41SDU-DK-1107

42 Urine Sediment Analysis) SDU-DK Cystine Cystine crystals are flat colorless plates and have a characteristic hexagonal shape with equal or unequal sides. They often aggregate in layers. Their formation is favored in acidic urine. Cystine crystalluria or urolithiasis is an indication of cystinuria, which is an inborn error of metabolism involving defective renal tubular reabsorption of certain amino acids including cystine. Sex-linked inheritance is suspected since male dogs are almost exclusively affected. Many breeds, as well as mongrels, have been reported affected. Renal function otherwise appears to be normal and, aside from a tendency to form uroliths, the defect is without serious consequence.

43 Urine Sediment Analysis) SDU-DK Biurates Ammonium urate (or biurate) crystals generally appear as brown or yellow-brown spherical bodies with irregular protrusions ("thorn-apples"). Though possible in urine of any pH, their formation is favored in neutral to alkaline urine. These crystals are fairly common in dogs and cats with congenital or acquired portal vascular anomalies, with or without concomitant ammonium urate uroliths. They can be seen in urine from normal Dalmatian dogs. Both Dalmations and Bulldogs are predisposed to urate urolithiasis. They are rarely, if ever, seen in urine from normal cats or dogs of other breeds.

44 Urine Sediment Analysis) SDU-DK Drug Crystals Many drugs excreted in the urine have the potential to form crystals. Hence, a review of the patients drug history is prudent when faced with unidentified urine crystals. Most common among these are the sulfa drugs. Both panels on the right are from patients receiving trimethoprim-sulfadiazine. The differing appearance may relate to variation in drug concentration, urine pH, and other factors. The upper panel is from a feline case, the lower from a horse. The inset in the lower panel shows the crystals as they appeared when polarized. Other examples include radiopaque contrast agents (Hypaque, Renografin) and ampicillin which may precipitate in acid urine as fine needle-like crystals (not shown).

45 Urine Sediment Analysis) SDU-DK Tyrosine Tyrosine crystals are usually seen as fine brownish needles. These can be associated with severe liver disease in humans, but they are very rarely seen in domestic animals. Calcium Oxalate Monohydrate Calcium oxalate monohydrate crystals vary in size and may have a spindle, oval, or dumbbell shape. Most commonly, they appear as flat, elongated, six-sided crystals ("fence pickets") such as shown to the right. The arrow in the photo indicates a "daughter" crystal forming on the face of a larger underlying crystal. We have not observed this form of calcium oxalate crystals in urine of normal dogs and cats, and believe their presence is virtually always associated with ethylene glycol intoxication.

46 Urine Sediment Analysis) SDU-DK Urinary Casts Composition: Tamm-Horsefall mucoprotein Composition: Casts are cylindrical structures composed mainly of mucoprotein (the Tamm-Horsefall mucoprotein) which is secreted by epithelial cells lining the loops of Henle, the distal tubules and the collecting ducts. The factors responsible for the precipitation of this mucoprotein are not fully understood, but may relate to the concentration and pH of urine in these areas. Casts may form in the presence or absence of cells in the tubular lumen. If cells (epithelial cells, WBC) are present as a cast forms, they may adhere to, and subsequently be surrounded by, the fibrillar protein network. Formation: A commonly-held theory is that cellular, granular, and waxy casts represent different stages of degeneration of cells in a cast. The appearance of a cast observed in a urine sediment depends largely upon the length of time it remained in situ in the tubules prior to being shed into the urine. A cast recognizable as "cellular", for example, was shed shortly after it was formed. A waxy cast, in contrast, was retained longer in the tubular system prior to being released (see figure).(see figure)

47 Urine Sediment Analysis) SDU-DK General Interpretation of casts: General Interpretation of casts: Casts are quantified for reporting as the number seen per low power field (10x objective) and classified as to type (e.g., waxy casts, 5-10/LPF). Casts in urine from normal individuals are few or none. Casts may be absent or very few in cases of chronic, progressive, generalized nephritis An absence of casts does not rule out renal disease. Casts may be absent or very few in cases of chronic, progressive, generalized nephritis. Even in cases of acute renal disease, casts can be few or absent in a single sample since they tend be shed intermittently. Furthermore, casts are unstable in urine and are prone to dissolution with time, especially in dilute and/or alkaline urine. Although the presence of numerous casts is solid evidence of generalized (usually acute) renal disease, it is not a reliable indicator of prognosis. If the underlying cause can be removed or diminished, regeneration of renal tubular epithelium can occur (provided the basement membrane remains intact).

48 Urine Sediment Analysis) SDU-DK Hyaline casts are formed in the absence of cells in the tubular lumen. They have a smooth texture and a refractive index very close to that of the surrounding fluid. Reduced lighting is essential to see hyaline casts. Lower the substage condenser. When present in low numbers (0-1/LPF) in concentrated urine of otherwise normal patients, hyaline casts are not always indicative of clinically significant renal disease. Greater numbers of hyaline casts may be seen in association with proteinuria of renal (e.g., glomerular disease) or extra-renal (e.g., overflow proteinuria as in myeloma) origin. In such cases it has been proposed that the presence of excessive serum protein in the tubular lumen promotes precipitation of the Tamm-Horsefall mucoprotein.

49 (Urine Sediment Analysis) Granular casts, as the name implies, have a textured appearance which ranges from fine to coarse in character. Since they usually form as a stage in the degeneration of cellular casts, the interpretation is the same as that described previously. 49SDU-DK-1107 Granular Casts

50 SDU-DK Urine Sediment Analysis) Fatty Casts Fatty casts are identified by the presence of refractile lipid droplets. The background matrix of the cast may be hyaline or granular in nature. Often, they are seen in urines in which free lipid droplets are present as well. Fatty casts are the most common type seen in cat urines. Interpretation of the significance of "fatty" casts should be based on the character of the cast matrix, rather than on the lipid content per se. Pictured here is a fatty cast with a hyaline matrix. Also notice the free lipid droplets in the background. Such droplets are most commonly seen in feline urine. As an isolated finding, lipiduria is seldom of clinical significance. Waxy Casts Waxy casts have a smooth consistency but are more refractile and therefore easier to see compared to hyaline casts. They commonly have squared off ends, as if brittle and easily broken. Waxy casts indicate tubular injury of a more chronic nature than granular or cellular casts and are always of pathologic significance

51 SDU-DK The appearance of red blood cells (RBC) in urine depends largely on the concentration of the specimen and the length of time the red cells have been exposed. Fresh red cells tend to have a red or yellow color (lower panel). Prolonged exposure results in a pale or colorless appearance as hemoglobin may be lost from the cells (upper panel). In fresh samples with S.G. of , RBC may retain the normal disc shape (upper panel). In more concentrated urines (>1.025), red cells tend to shrink and appear as small, crenated cells (lower panel). In more dilute samples, they tend to swell. At urine S.G. <1.008 and/or highly alkaline pH, red cell lysis is likely. Lysed red cells appear as very faint "ghosts", or may be virtually invisible. Cells in Urine Sediment (Urine Sediment Analysis)

52 SDU-DK Urine is a hostile environment for cells since they encounter abnormal osmotic pressures, pH changes, and exposure to toxic metabolites. For these reasons, post-collection delay of examination should be minimized. If delay is unavoidable, refrigeration will slow degeneration of cells. For routine purposes, cells are examined as unstained wet-mounts of sedimented urine. Under some circumstances, air-dried smears are prepared and stained with hematologic stains. Red blood cells and leukocytes are quantified as cells/HPF (High Power Field - 40x objective). Other cell types are usually subjectively listed as "few, moderate, or many". Click on the buttons below for pictures and more discussion of various types of cells in urine.RBC RBC (Urine Sediment Analysis)

53 SDU-DK Red blood cells up to 5/HPF are commonly accepted as normal. Increased red cells in urine is termed hematuria, which can be due to hemorrhage, inflammation, necrosis, trauma, or neoplasia somewhere along the urinary tract (or urogenital tract in voided specimens). The method of collection must be considered in interpreting hematuria to aid in localizing the source, and because catheterization, cystocentesis, and manual compression can induce hemorrhage. Last Updated: January 15, 1996 Red Blood Cells (Urine Sediment Analysis)

54 SDU-DK White Blood Cells White blood cells White blood cells (WBC) in unstained urine sediments typically appear as round, granular cells which are times the diameter of RBC. The details of nuclear shape often are difficult to discern, especially if the specimen is not fresh. WBC in urine are most commonly neutrophils. Staining of air-dried sediment smears with a hematologic stain sometimes is useful for more specific identification. Like erythrocytes, WBC may lyse in very dilute or highly alkaline urine. WBC up to 5/HPF are commonly accepted as normal. Greater numbers (pyuria) generally indicate the presence of an inflammatory process somewhere along the course of the urinary tract (or urogenital tract in voided specimens). Pyuria Pyuria often is caused by urinary tract infection, and many times bacteria can be seen on sediment preps. Depending on clinical signs, pyuria may be an indication for culture of urine even if no bacteria are seen. Non-septic causes of inflammation, such as uroliths and tumors, also must be considered. (Urine Sediment Analysis)

55 SDU-DK TEriMa KAsih


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